The Challenge to Change

Front matter

THE CHALLENGE TO CHANGE

Reforming Health Care on the Front Line in the United States and the United Kingdom

ON Mi) ay d T

Contents

Acknowledgments ix List of Abbreviations xiii Introduction 1

1. Health Care Systems in the United States and the United Kingdom: A Lifetime of Change 26

3. Measuring and Rewarding Performance: Imposing Change from above in the United Kingdom 68

Index

175 195

ACKNOWLEDGMENTS

The book you hold in your hands or see on your screen has been through a long journey, with perhaps an even higher number of twists and turns than are found on the usual scholarly roller coaster. I owe an enormous number of people a debt of gratitude for their support of this project as it evolved and unfolded. I am indebted to the dozens of interviewees (many of whom remain anonymous) who took the time to talk with me and share their experiences.

Stephen Bach has been a terrific collaborator and friend. Chapter 5 is based on joint research we conducted on Private Finance Initiative hospitals, some of which was previously published (Bach and Givan 2010). This research was originally conducted under the auspices of the Future of Unions in Modern Britain program at the London School of Economics, funded by the Leverhulme Trust. Colleagues in the United Kingdom, particularly at both the London School of Economics and Cardiff Business School, have provided crucial support and input at various stages of this research. Special thanks go to Rick Delbridge, Ed Heery, Sarah Jenkins, John x Acknowledgments

Kelly, Ian Kessler, David Metcalf, and Pete Turnbull. Chris Howell probably bears some responsibility for encouraging my interest in all this over two decades ago; he has been an invaluable mentor and friend. Thanks to Lena Hipp, Ruth Milkman, Ofer Sharone, Chris Tilly, and many seminar and conference participants who helped advance my thinking at some key points. The late Clete Daniel, James Gross, and David Lipsky all offered unfailing support. My thinking about employment relations in health care has been influenced and advanced by ongoing conversations with Darlene Clark, Paul Clark, Jody Hoffer Gittell, Peter Lazes, Adam Seth Litwin, and my ally and frequent collaborator, Ariel Avgar. Monica Bielski Boris remains a dear friend, trusted colleague, and fellow traveler. My students have consistently kept me on my toes. I have learned an enormous amount from so many of them—I am grateful especially to Elise Blasingame, Chad Gray, Tashlin Lakhani, Kelly Pike, and Maite Tapia for helping me think and learn.

Colleagues and comrades at Rutgers University have created an unusually supportive environment. Thanks in particular go to David Feingold, Janice Fine, Tamara Lee, Mingwei Liu, Fran Ryan, Tobias Schulze-Cleven, Susan Schurman, and Paula Voos. Adrienne Eaton deserves special acknowledgment for years of quiet mentorship and support, and for providing a model of rigorous, engaged scholarship coupled with uncompromising integrity.

Suzanne Gordon pushed me to think longer, harder, and most importantly bigger as I worked on this book. Holly Bailey is a brilliant and perceptive editor. Fran Benson waited patiently for this book and offered wise counsel along the way. Susan Bloom and Michael Bosia have been in on this project (and many others) since it was something quite different. They never fail to provide an editorial eye or a sympathetic ear, and I am so grateful to each of them. Steven Obranovich is a compassionate friend, and a gifted chef, and I’m lucky to know him.

Many colleagues have become friends without whom things would be much less lively. Thanks are insufficient for the support and good times provided by Rachel Ashworth, Richard Belfield, Jo Blanden, Teresa Casey, Chris Crowe, and Olivier Marie. Daphne Jayasinghe and Alison McDowell are key members of the Massive. The Donaldson family, the Jayacrowe family, and Catherine Lock, have opened their homes to me on my frequent research trips to the United Kingdom. The Wallace family has also housed

Acknowledgments xi me on research trips and on the many occasions when I just needed to recharge. Yael Kropsky and Milena Robcis provided diversions when (and where) they were most needed. Cary Howie offered a constant supply of good humor, while navigating roadblocks, U-turns, and more.

There are so many other people who have given help in seeing this book to completion—mostly in knowing when I wanted to talk about it and when I did not. These indispensable friends include Emily Franzosa (and the 11 a.m. writing group); David Berman, Howard Yaruss, and the NYC Exploration Society; Michael Maccaferri, who is always on and always on fire; Stef Adams, Ellen Baxt, Margaret Ewing, David Geraghty, Ivan Geraghty, Jacob Greenberg, Amy Holmes, Nate Horrell, Matthew Hunter, Jen Izak, Heather Johnson, Daphne Kouretas, Pam Lowy, Stephanie Luce, Krissy Mahan, Katie McCall, Tom Medvetz, the Nyzito family, the Olney family, Masha Raskolnikov, Mark Rimbach, Maggie Russell-Ciardi, Ary Shalizi, FaTai Shieh, Noemi Sicherman, Sarah Soule, and Rhiannon Welch.

My family has been with me throughout, reminding me of what really matters. I thank Ben Givan, and most of all I thank my parents. This book is dedicated to them.

AARP ACA ACAS ACO

ACS

AFC AFL-CIO

AHA ANA BMA CMS CNA GAO GP HIV

ABBREVIATIONS

American Association of Retired Persons Affordable Care Act of 2010

Advisory, Conciliation and Arbitration Service Accountable Care Organization

American College of Surgeons

Agenda for Change

American Federation of Labor-Congress of Industrial Organizations

American Hospital Association

American Nurses’ Association

British Medical Association

Centers for Medicare and Medicaid Services California Nurses Association

US Government Accountability Office General Practitioner

Human immunodeficiency virus xiv

HMO JCAH JCAHO

MP NHS OSHA PFI PPO RCN SEIU TUPE

UAN VA WHO

Abbreviations

Health maintenance organization

Joint Commission for the Accreditation of Hospitals Joint Commission on Accreditation of Healthcare Organizations (now the Joint Commission)

Member of Parliament

National Health Service

Occupational Safety and Health Administration Private Finance Initiative

Preferred Provider Organization

Royal College of Nursing

Service Employees International Union

Transfer of Undertakings (Protection of Employment) Regulations

United American Nurses

Veterans Administration

World Health Organization

THE CHALLENGE TO CHANGE

Introduction

On the eightieth anniversary of the British National Health Service (NHS), US physician Don Berwick, an unabashed fan, gave a speech expressing his great love for the NHS. “There comes a time, and the time has come,” he said, “for stability, on the basis of which, paradoxically, productive change becomes easier and faster, as the good, smart, committed people of the NHS—the one million wonderful people who can carry you into the future—find the confidence to try improvements without fearing the next earthquake” (Berwick 2008). In the same speech Berwick lamented the US health care system, which he characterized as a “duplicative, supply-driven, fragmented care system” (Berwick 2008). This book examines the tension between productive improvements and unproductive “earthquakes” in both the United States and the United Kingdom. This tension is, indeed, the core problem for anyone hoping to improve health care quality anywhere.

For over a decade I have listened intently as workers and managers have described the myriad new initiatives pouring down upon them, constantly interrupting their ability to provide high quality and appropriate health care.

Policymakers routinely believe they have found a panacea—a single change that will dramatically improve health care outcomes, lower costs, or even do both. As one frustrated hospital manager told me when I asked if he was adequately consulted over new initiatives, “they do consult us; it’s not clear whether they ever listen to the answers” (personal interview, March 28, 2002). This sentiment was echoed by scores of frontline workers and their managers over my years of research in hospitals in two countries, demonstrating the true challenge of implementing worthwhile change in hospitals.

In the United States and United Kingdom, health care workers, tiring of constant attempts to improve efficiency or measure performance, are complaining about their great weariness with change, sometimes known as change fatigue. In this book I examine how health care change has been implemented in hospitals in these two countries and historically what factors have combined to make meaningful, lasting change. Hospitals are the site of the preponderance of health care delivery (whether measured in patient acuity, employment, or expenditures), and they are also the most complex, sophisticated organizations in the health care sector.

Health care payers, regulatory bodies, and policymakers send initiative after initiative into the workplace, where frontline staff struggle with the constant dilemma of how to care for their patients while simultaneously pursuing initiatives that have come from outside their organizations. The push from policymakers, executives, and insurers for transformation, change, and reform in health care delivery is incessant (Berwick 2008). Private organizations, politicians, and regulators continue to push to improve performance, reduce waste, and spread best practices in hospitals. Health care providers are being encouraged or required by payers and regulators to do more with less. To comply with the onslaught of new rules and regulations, providers are expected to implement massive new information technology systems that will digitize service delivery and medical records, reduce medical errors, and make health care more patient-centered. At the same time, hospitals on both sides of the Atlantic have been required to measure everything they do and to demonstrate their high level of performance (Bevan and Hood 2006; Chassin et al. 2010).

Although health care leaders and managers around the world have been constantly preoccupied with productivity and performance, they also have a newer concern. Between 1999 and 2000, influential reports in both the United States and the United Kingdom highlighted the startling cost in human life as well as money of medical errors (Department of Health 2000, 2001; Gaffney et al. 1999; Kohn, Corrigan, and Donaldson 2000). In the United States, for example, an influential Institute of Medicine report estimated that 98,000 deaths were caused by medical errors each year, but more recent estimates suggest the figure may be as high as 400,000 deaths per year (James 2013; Kohn, Corrigan, and Donaldson 2000). Groups such as the Institute for Health Care Improvement in the United States and the National Patient Safety Agency in the United Kingdom, among many others, began to push for patient safety around the year 2000. Recent research suggests that the problem is still quite serious and that morbidity and mortality resulting from medical errors may be at far higher levels than even the earlier, attention-getting estimates (James 2013). Most of the patient-safety initiatives have been accompanied by the introduction of new technologies such as electronic medical records. Thus, payers and policymakers ask managers and frontline staff to master new computer systems, which may have their own pitfalls and introduce threats to patient safety (Koppel et al. 2005). Hospital workers and managers have therefore had to contend with yet another series of change initiatives and scoring mandates, with an attendant set of penalties for noncompliance.

Numerous public and private organizations, including the Institute for Healthcare Improvement and the Joint Commission in the United States, and the National Institute for Clinical Excellence and Dr. Foster Intelligence (an independent, university-based research body), have launched dozens of programs spotlighting the need for everything from hand-washing to team communication. Many of these vaunted programs, such as the Six Sigma Black Belt, engage only the top managers and lead physicians in a hospital and leave the key issue of staff engagement to chance (Dunn 2014). Managers and staff are somehow expected to incorporate these new initiatives into their practices while also dealing with a labor shortage in most of the skilled professions and higher demands from an aging population and improved medical technologies.

From metric-driven performance monitoring to the patient-safety movement, the only constant is change. Civil servants, researchers, and consultants craft and bring into the hospitals a cascade of change and reform initiatives with no clear rationale, and they ask managers, professionals, and other workers to accept and implement these new ideas. These initiatives often rely on highly paid external consultants to implement programs such as lean production, Six Sigma, and Hardwiring Excellence to reengineer work processes, frequently from the top down, relying on approaches imposed by outsiders without frontline experience (Vest and Gamm 2009). In spite of change fatigue and skepticism from workers about the results of initiatives that have been launched only to fail, managers and professionals seemingly face no choice but to accept, adopt, implement, and adapt these initiatives.

Enormous amounts of time, money, and energy are devoted to this process of implementation, adaptation, and acceptance. Hospital managers and staff are frequently held accountable for the successful implementation of these initiatives. At the top of the health care hierarchy, policymakers and consultants make sweeping promises about the benefits of their change initiatives. As they throw around concepts such as streamlining, efficiency, quality, and excellence, they have created a whole new health care jargon equipped with “pillars” and “belts” and lean production processes. They argue that these will produce better health outcomes at lower cost and will provide patient-centered care with greater patient satisfaction. Frontline staff—whether management, professionals, or support staff—seem to have little choice but to acquiesce to these initiatives. But they often find it difficult to initiate their own changes.

Critical Questions

What are the results of all these promises, time, and money? Do big ideas from outside the hospitals improve health care outcomes? Is change best when it is imposed from above? Does the relentless quest for change produce better patient care, greater efficiencies in health care, quality services, or even dramatic cost savings? If not, what are the results of these initiatives? When do they prompt acceptance and when do they provoke resistance? How do the organization of the workplace and its complex relationships influence the acceptance of change imposed from the outside? When and how do managers and professionals try to shape these programs to suit their own and their patients’ needs? Do they succeed? Or is what results a constant series of compromises and adaptations to adaptations? When does change move from the macro to the micro, and when is the opposite true?

Over the past two decades, my work has been devoted to the health care systems in both the United States and the United Kingdom. As a long-term resident at various times and a citizen of both countries, I have become a keen observer and analyst of the evolving health care system in each. In this book I try to answer the critical questions I have just posed by examining a series of change initiatives as they are experienced at the front line in what appear to be two entirely dissimilar health care systems—the largely privatized system in the United States and the highly “socialized” (publicly funded and publicly provided) system in the United Kingdom. Using concrete examples of organizational and even systemwide change in these case studies, I investigate what happens when change is initiated both from above and from below.

I have found that wherever its point of departure in the complexities of the contemporary hospital, successful organizational change requires a deep level of acceptance and commitment not only from managers but also from staff on the front line. Indeed, some of the most successful health care change initiatives have been launched at the frontline level where workers responded to serious problems they had identified and struggled to remedy them, not only in their institutions but at the national or state level. Thus, I challenge the widely accepted notion that successful change is launched from above and trickles down with my analysis of how change also trickles up when frontline staff launch initiatives that eventually affect national policy.

A huge proportion of the research on health care change focuses on change initiatives that are launched by elite players such as CEOs, hospital administrators, or physician pioneers, and it neglects the possibility that change can also move up from the front line (Berry and Seltman 2008; Lee 2004). The general literature on management and health care change management has devoted an enormous amount of attention to those who make sweeping promises that the latest new initiative will prove a panacea that provides both quality and efficiency without a downside. The focus is on visionary leaders and their heroic and ultimately successful struggles to transform the corporation or hospital from top down (Berwick 1996, 2003; Pronovost et al. 2006). In this literature, workers—whether physicians or janitorial staff—are depicted as being afraid of change and as obstacles whose irrational resistance to change must be overcome.

In this book, however, I offer a more nuanced account. I examine the dual dynamic of health care delivery change in detail and with balance. I show how high-level initiatives may indeed be distorted or subverted in hospitals, but I also explore why change is often resisted at the frontline level— sometimes with good reason—and try to help readers understand which top-down changes are resisted and why, and which are accepted, adopted, and sometimes constructively adapted and why.

While I analyze worker resistance to top-down change initiatives, I look beyond this to focus as well on a dynamic that has received very little attention: how changes initiated by frontline staff may trickle up to become policy at the macro level. These policies have produced positive changes that in turn have had significant impacts on safety, performance, and productivity. I argue that nonimplementation of a policy by frontline staff, such as occurred in the subversion of performance indicators in the United Kingdom, can shape future policy in surprising ways (see chapter 3). I also show how change can be initiated by workers while they are addressing problems that management seems to ignore and are struggling to transform the workplace in ways that make health care and the hospital safer for both patients and those who care for them. This crucial work is explored in chapter 6, which examines staff-driven initiatives to create a safety culture in hospitals that benefits both patients and employees.

Where unions are present, they play a key role in the implementation or obstruction of workplace change as well as influencing the development of policies at the national level. Key contributions of the health care unions cannot be ignored. In the United Kingdom, NHS hospitals are unionized, with a number of unions representing different occupational and professional groups; in the United States, union membership varies considerably by workplace and region across the health care industry (Milkman and Luce 2014). Although many politicians view unions as obstructionist, clinging to rigid contract language, and unwilling to embrace change, the reality is quite different. Health care unions play key roles in ensuring high-quality patient care, from facilitating ongoing communication to drawing attention to immediate problems such as poor infection control and unmet patient needs. In fact, well-run local unions with talented stewards frequently initiate change that may improve performance for everyone in the hospital—patients, staff, and management alike. As the organized voice of frontline health care workers, unions are well-positioned to identify problems and to suggest solutions in the delivery of care.

I do not presume that the role of unions is monolithic. Instead, my analysis starts from the observation that unions organize the voice of their members, and in this role they may be either proponents of or impediments to change. I examine the specific work of unions where they are present (almost everywhere in the UK health economy, and only in concentrated pockets in the United States). The chapters ahead highlight several cases in which unions have facilitated positive change, and they demonstrate that the view of unions as obstacles to change is at best antiquated and is more likely simply motivated by ideology rather than experience.

Contrasts and Commonalities

Ina letter to The Guardian in May 2015, at a time when the NHS was a key issue in the imminent election, a group of dozens of American doctors urged the British public to proceed with caution. They affirm how much the providers in these two systems look to each other:

There are many things the US healthcare system has to admire, such as our pioneering integrated care organizations and our world-leading medical research and high-tech rescue care. At the same time, the US is in the midst of a major healthcare reform effort that aims to bring affordability and equity to American healthcare. We caution the UK against moving in the direction of a system that has created the inequality in US that we are now working to repair. Your universal, public healthcare system is an example to the world, and something of which Britain should be proud. We urge you to preserve it. (Wang 2015)

These two countries with a common language, a common model of health care provision, and a dramatically different model of health care financing have long held an interest in each other. As both these systems contemplated changes over the last several decades, their mutual awareness of each other became evident. As privatization debates continued in the United Kingdom, observers sought evidence from the private US health care system. On the occasions that single-payer health care was discussed in recent decades in the United States, the key exemplar tended to be the United Kingdom (Light 2003). Articles with titles such as “What Are the Lessons from the USA for Clinical Commissioning Groups in the English National Health Service?” (Ham and Zollinger-Read 2012) and “A healthy debate? The US and English Health Systems” (Thorlby 2009) cropped up across the top medical, health policy, and even news publications in the United Kingdom. When private companies were given the opportunity to bid on NHS contracts, many US-based providers saw a key opportunity for profit. When a crisis of poor-quality care and high mortality rates hit the Mid-Staffordshire health care system, the US physician Don Berwick was brought in to investigate the mess. In his letter accompanying his report to senior NHS executives and government officials, he wrote, “You are stewards of a globally important treasure: the NHS” (Berwick 2013, Annex B).

This mutual awareness has often been colored by mutual suspicion. When Simon Stevens, a Brit who had spent almost a decade working in the United States as a top executive for UnitedHealth, was appointed the chief executive of NHS England in 2013, UNISON, the major public service union, responded by saying, “We sincerely hope this is not a sign that the government wants to import America-type values into the NHS and look at ways of developing healthcare through an insurance model” (UNISON 2013). Indeed, through my ongoing research on change in the two systems, I have discovered firsthand how each system looks to the other, and I have heard countless interviewees express interest, fascination, and horror in the other country’s health system.

In comparisons of health systems in developed countries, the UK and US systems frequently fall at opposite poles. For example, in the Commonwealth Fund’s periodic international comparison of eleven developed countries’ health care systems, the United Kingdom ranks first in eight categories as well as in overall ranking whereas the United States ranks last in four categories and dead last in overall ranking (Davis et al. 2014).

Likewise, in terms of access to and payment for medical services, the US and British health care systems probably differ the most of any two in the industrialized world. The British NHS is a massive, fairly centralized single-payer, single-provider health care system. It is financed through taxation, health care providers are public employees, and access to health care is universal. In the United States, the payers and providers are far more diverse. Although the government purchases health care for more than 100 million people (including those eligible for public programs as well as public employees), most health care is purchased by employers, with a small proportion purchased by private individuals. Before the Affordable Care Act (ACA) of 2010, this fragmented system left about 50 million people without any access to health care except in the case of emergency, a far cry from the universal coverage of the NHS.

In terms of payment, the systems differ not only in who pays for health care but in how the payment systems operate. In the United States, the payment systems create massive profits for many of the stakeholders and also provide a system of incentives that do not necessarily align with the goals of providing widespread, high-quality, and efficient health care. The NHS has relatively simple payment systems in which most providers receive salaries and the system uses its large-scale purchasing power to negotiate prices on drugs, devices, and diagnostic equipment. The story is quite different in the United States, where the system is rife with incentives to treat more: doctors and hospitals profit by providing more treatment, regardless of the quality of care or the outcomes (Brownlee 2008). Physician and health care innovator Don Berwick has referred to the US system as “supply-driven care” (Berwick 2008). This is the opposite of the UK system, which is able to focus on a broad public health strategy, prevention, and a long-term outlook.

In spite of these differences, when one looks beyond access and payment into the health care workplaces, there are striking similarities. In hospitals in both countries, work organization is structured around strong, historically entrenched professional boundaries. The often-fraught relationship between nurses and doctors is almost perfectly mirrored by hospitals in both countries. Health care providers are subject to similar challenges, such as ever-changing treatment protocols, advances in technology, and the health care needs of an aging population. Both systems face shortages of professionals, and they rely on recruiting workers from abroad. Trends in patient care, such as the patient-safety movement, penetrate both systems, generating particular pressures on the health care providers. The US system may appear to be fragmented in terms of access and payment, but the role of putatively voluntary regulators, especially the Joint Commission, means that no hospital is immune from centrally determined requirements that range from specific treatment protocols to cleanliness standards.

In this book I address another characteristic shared by the two systems: both are subject to concerted pressure to change, and their experiences with change initiatives have telling similarities.

10 Introduction Change as It Actually Happens on the Front Lines

To explore these US and UK experiences in detail, I use personal interviews as well as documentary research to focus on four historical cases from the past decade (Table 1): in the United Kingdom, the introduction of the star rating system and the advent of privatization; in the United States, regulation by the Joint Commission and the development of a safety culture. Two cases are examples of change imposed from above, and two cases examine change initiated at the front line. I have chosen each case because it represents a crucial moment in the development of the current health care system and also traces a key ongoing trend in the Anglo-American health care model: accountability, centralized regulation, privatization and resistance, and the turn to quality. These four forces are acting on both the UK and US health care systems, even while each system has a different starting point in its current institutional configuration.

The cases I present offer evidence about the front line that moves beyond stereotypes of health care workers as frightened of change or as obstacles that invariably halt promising initiatives in their tracks. I focus instead on feedback effects that are instrumental in shaping future attempts to reform and restructure hospitals. Health care workers on the front line play a crucial role in shaping change. It is essential for would-be reformers to understand how change actually works in these complex institutions if they are to assess accurately the chances for implementing change at either the macro or the micro level. Without this deeper understanding, the parade of new initiatives, never fully implemented, will doubtless continue but will rarely cause actual improvements in the delivery of health care.

Table 1. Case studies

Case type United Kingdom United States Change from above Star rating performance Joint Commission Accreditation measurement Central regulation

Accountability

Change from below Response to privatization Movement for a safety culture

Privatization and resistance Quality

My research on these cases is primarily qualitative and uses a multistakeholder, vertical-slice approach; that is, I have attempted to interview representatives of all the key stakeholders at all levels, from policy to practice. I also rely on primary and secondary documents, including government publications and employer and union-produced materials, to construct accurate accounts that include the perspectives of all relevant stakeholders. My interviewees included frontline health care workers and managers, local, regional, and national union representatives, and bureaucrats and elected officials. Most of the interviews in the United Kingdom were conducted between 2002 and 2007, with a few later interviews in subsequent years. The US interviews were primarily conducted from 2007 to 2014. I summarize the interviews and offer select representative quotations. Most interviews were conducted individually, for thirty to ninety minutes, although there were a handful of group interviews (from a two-person interview to a ten-person focus group) and a small number of telephone interviews as well. The high-level interviewees, such as those from national regulators, were specifically selected for their expertise. The frontline interviewees were selected in hospitals that represented the diversity of hospital workplaces in each country.

These interviews, as well as extensive documentary research, make up the empirical data used throughout the book. These diverse perspectives illuminate the sometimes conflicting interests of the different stakeholders in health care. Although I have not interviewed patients for this study, the research is informed, where appropriate, by patient data, including surveys reflecting patient satisfaction as well as quantitative measures of clinical outcomes. Elsewhere in my research, I have given patient sources a great deal more emphasis (see, for example, Avgar, Givan, Liu 2011a, 2011b; Givan, Avgar, Liu 2010). Although there is occasionally patient-led change in the provision of health care, this is a rare occurrence compared with change initiated by frontline providers or national regulators.!

1. The best example of patient-led change is probably the change in labor and delivery practices as part of the women’s movements of the 1960s and 1970s. Women wrested some control of their delivery environments from doctors, and forced doctors and hospitals to allow partners and others chosen by the birthing mother to remain in the delivery room. Expectant mothers chose hospitals that would allow them this control over their birthing environment, and this competition then drove widespread adoption of the new practice. My thanks to Ellen Berman for suggesting this example of patient-driven change in health care delivery.